Pediatric SCR Discussion of Complex Clinical Scenarios NSQIP Annual Meeting July 26, 2015

Transcription

1 Pediatric SCR Discussion of Complex Clinical Scenarios NSQIP Annual Meeting July 26, 2015

2 Scenario 1: Postoperative SSI A 16 year-old patient Principal Operative Procedure: Incision and Drainage for monoarticular Septic arthritis of the hip On POD 5, the operative note indicates the purulent fluid was encountered at the superficial layer with a tracking to right hip joint. Which wound occurrence(s) would be assigned to this case? A C D Organ Space SSI and Superficial Incisional SSI Organ Space SSI Deep Incisional SSI Superficial Incisional SSI

3 Scenario 1: Postoperative SSI A 16 year-old patient Principal Operative Procedure: Incision and Drainage for monoarticular Septic arthritis of the hip On POD 5, the operative note indicates the purulent fluid was encountered at the superficial layer with a tracking to right hip joint. ANSWER C Deep Incisional SSI Rationale: There is evidence of an Organ Space infection which is draining to the superficial layers. Per Chapter 4 guidance an organ/space SSI that drains through the incision is reported as a deep incisional SSI

4 Scenario 2: Postoperative SSI Term neonate, first day of life Principal operative procedure: closure of a myelomeningocele defect On POD 8 the wound develops erythema. o Patient has a fever of 39.2⁰ C and WC 20. o NICU physician progress note documents upper 1/2 of incision dehisced. o Wound culture was obtained and grew E.coli, Extended spectrum beta-lactamase (ESL)-producing organisms. POD 10, CSF fluid is noted to be draining through the incsision. o A CSF culture is obtained and was positive for E.coli ESL.

5 Scenario 2: Postoperative SSI ased on the previous information which incisional SSI occurrence(s) would be assigned to this case? A C D Organ Space SSI and Deep Incisional SSI Organ Space SSI Deep Incisional SSI Superficial Incisional SSI

6 Scenario 2: Postoperative SSI ANSWER C Deep Incisional SSI Rationale: There is evidence of an Organ Space infection which is draining through the incision. Per Chapter 4 guidance an organ/space SSI that drains through the incision is reported as a deep incisional SSI.

7 Scenario 3: Postoperative PNA 13 year-old patient POD 5, temperature of 38.4 C. o chest X-ray is noted to be concerning for pneumonia but no description of infiltrate, consolidation, opacity, or cavitation is provided. o Patient required 2L NC due to desaturations. o Physical exam: patient is noted to have rhonchi and a new cough. ased on the above information which respiratory occurrence would be assigned to this case? A Unplanned Intubation/Reintubation with Vent Support C D Pulmonary Embolism Pneumonia None

8 Scenario 3: Postoperative PNA ANSWER C Pneumonia Rationale: This case meets NSQIP criteria to assign pneumonia. In this case, the documentation of the radiologic exam notes concerning for Pneumonia, which now meets criteria of a positive x-ray. The patient also has evidence of a fever (38.4), a new cough, and increased oxygen requirements.

9 Scenario 4: Postoperative Sepsis A 16 year-old patient Principal Operative Procedure: Incision and Drainage for monoarticular Septic arthritis of the hip Preoperative and intraoperative cultures were positive for growth of Staphylococcus aureus. The patient met SIRS criteria within 48 hours before the principal operative procedure. On postoperative day 4 the patient had a fever >38 C, heart rate 115, and pain. On POD 5, the patient returned to the operating room for an Incision and Drainage. Purulent fluid was encountered. The culture of purulent fluid, returned positive for Staphylococcus aureus.

10 Scenario 4: Postoperative Sepsis Which level of postoperative Sepsis would be assigned to this case? A C D SIRS Sepsis Septic Shock None

11 Scenario 4: Postoperative Sepsis ANSWER D None Rationale: Postoperative Sepsis would not be assigned to this case because there is no new source of infection.

12 Scenario 5: Inclusion/Exclusion A NICU patient had a small bowel resection which was abstracted 2 months ago which resulted in short gut syndrome. Now on your operative log for an exploratory laparotomy/step procedure due to failure to progress with enteral feedings. The exploratory laparotomy/step procedure was performed within the same admission as the small bowel resection. Is the exploratory laparotomy/step procedure eligible for abstraction as a Principal Operative Procedure? A C D Exclude as a complication of the small bowel resection. Exclude as it occurred within the same admission. Include the exploratory laparotomy/step as Principal. Exclude because the bowel resection was abstracted in NSQIP.

13 Scenario 5: Inclusion/Exclusion ANSWER C Include the exploratory laparotomy/step as Principal. Rationale: The exploratory/step procedure can be abstracted in NSQIP because it would not be considered a complication but a surgery necessitated by disease process.

14 Scenario 6: Wound Disruption Principal operative procedure lumbar meningomyelocele repair POD 10, swelling at the incision. o No evidence of skin separation. o CT scan confirms lumbar pseudomeningocele. Which wound occurrence would be assigned to this case? A C Superficial wound disruption Deep wound disruption None

15 Scenario 6: Wound Disruption ANSWER C None Rationale: The definition of a Deep Wound Disruption/Dehiscence is that all layers of the wound (skin, subcutaneous tissue, muscle, fascia) have opened spontaneously. Even if the patient had been taken to the OR immediately, the intact skin and subcutaneous tissue preclude assignment as a Deep disruption.

16 Scenario 7: Postoperative Sepsis Term neonate, first day of life Principal operative procedure: closure of a myelomeningocele defect POD 8 o blood cultures positive for Staphylococcus aureus. o Patient has a fever of 39.2⁰ C and WC 20. POD 10, the patient continues to have an elevated white count and episodes of apnea. ased on the above information which level of Postoperative Sepsis would be assigned to this case? A C D SIRS Sepsis Septic Shock None

17 Scenario 7: Postoperative Sepsis ANSWER Sepsis Rationale: To assign Sepsis the patient must meet SIRS and Infection Criteria. In this scenario Infection Criterion A would be applied because there is no evidence of infection during the principal operative procedure or a reoperation. For Infection Criterion A, SIRS must be present 48 hours before or after any of the infection findings. In this case, the patient met SIRS criteria with documented apnea and an elevated white count (term infant 7 days to <30 days) within 48 hours of the positive blood culture. A positive blood culture does not require physician correlation. Sepsis would be assigned to this case as SIRS and Infection Criteria are met.

18 Scenario 8: Documentation for Postoperative Occurrences Determine whether or not information given meets variable criteria to assign Documentation/follow up info must meet variable criteria to assign Assume information is within 30 day postoperative timeframe

19 Scenario 8: Documentation for Postoperative Occurrences A parent sent the surgeon a photograph of the patient s spinal fusion wound, which you can see in the EMR; the incision is red with what looks like a small opening at one end, but there are no notes from the surgeon s office about the photograph. Would the occurrence of Superficial Wound Disruption be assigned to this case? A Yes No

20 Scenario 8: Documentation for Postoperative Occurrences ANSWER No Rationale: SSI or Wound Disruption MD/NP/PA written diagnosis/description or parent report must be obtained

21 Scenario 9: Cardiac Intervention 8-week-old former 24-week gestation infant. Principal operative procedure exploratory laparotomy with an open ileostomy in the Neonatal Intensive Care Unit Status post PDA closure with indomethacin. The patient s active problems include: Feeding problems in newborn Disturbance of temperature regulation of newborn Pulmonary immaturity ilateral grade II intraventricular hemorrhage Patent ductus arteriosus Anemia of neonatal prematurity Persistent pulmonary hypertension Cholestasis of parenteral nutrition Unspecified intestinal obstruction Congenital Hypothyroidism

22 Scenario 9: Cardiac Intervention What should be assigned for Previous Cardiac Surgery/Cardiac Intervention? A Yes No

23 Scenario 9: Cardiac Intervention ANSWER No Rationale: In this scenario, the PDA was closed by the administration of the drug Indomethicin. Indomethicin would be considered Pharmacologic Management and not Cardiac Surgery/Cardiac Intervention.

24 Scenarios 10, 11, 12: Documentation for Postoperative Occurrences Determine whether or not information given meets variable criteria to assign Documentation/follow up info must meet variable criteria to assign Assume information is within 30 day postoperative timeframe

25 Scenario 10: Documentation for Postoperative Occurrences Parent calls for advice stating she thinks patient s repaired cleft palate has new hole Would a wound occurrence be assigned to this case? A Yes No

26 Scenario 10: Documentation for Postoperative Occurrences ANSWER No Rationale: Further evaluation/documentation of exam findings by MD/PA/NP, or additional information from parent regarding incision needed to consider Superficial or Deep (oronasal fistula) Wound Disruption.

27 Scenario 11: Documentation for Postoperative Occurrences At postoperative visit, surgeon s NP documented that patient had superficial surgical site infection and prescribed antibiotics without noting incision appearance Would a Superficial Incisional SSI be assigned to this case? A Yes No

28 Scenario 11: Documentation for Postoperative Occurrences ANSWER A Yes Rationale: MD/PA/NP diagnosis alone is enough to assign Superficial SSI

29 Scenario 12: Documentation for Postoperative Occurrences Attending physician documented that patient has pneumonia on readmission. Would the occurrence of Pneumonia be assigned to this case? A Yes No

30 Scenario 12: Documentation for Postoperative Occurrences ANSWER No Rationale: Physician Pneumonia diagnosis alone not sufficient; pneumonia criteria must be met.

31 Scenario 13: Postoperative Sepsis 12-year old patient Colectomy is the principal operative procedure. Abscess with pus was noted in operative report. Intraoperative cultures were positive for group C Streptococcus and acteroides. Sepsis within 48 Hours Prior to Surgery was assigned. POD 1 o 38.8 C o Heart Rate 130 Which level of Sepsis would be assigned to this case? A C D SIRS Sepsis Septic Shock None

32 Scenario 13: Postoperative Sepsis ANSWER D None Rationale: In this scenario Sepsis within 48 hour was assigned. For an event to be considered a Postoperative Occurrence of Systemic Sepsis when sepsis was present preoperatively there must be a new source of infection. A new source of infection was not identified in this case; therefore, postoperative Sepsis would not be assigned.

33 Scenario 14: Postoperative PNA A 14 year-old male Principal operative procedure: appendectomy. Postoperative day 4 o patient arrived to ED complaints of pleuritic chest pain and shortness of breath. Physical exam: o Rhonchi o Diminished breath sounds, o Respiratory rate is 16 o Oxygen saturation on room air is 95% o White blood cell count is 3.0 The attending physician notes: chest x-ray negative but clinical picture consistent with pneumonia. Chest X-ray Impression: No acute pulmonary process. No focal pulmonary consolidation is seen. No pleural effusion or pneumothorax is identified.

34 Scenario 14: Postoperative PNA Would the postoperative occurrence of Pneumonia be assigned to this case? A C D This would be assigned because the patient was treated. This would be assigned because of the physician diagnosis. This would not be assigned because the patient was on RA. This would not be assigned because X-ray criteria are not met.

35 Scenario 14: Postoperative PNA ANSWER D This would not be assigned because X-ray criteria are not met. Rationale: This case does not meet NSQIP criteria to assign pneumonia. In this case the documentation of the radiologic exam does not note a new or progressive and persistent infiltrate, Consolidation or opacity (e.g. air-space disease, patchy areas of increased density, focal opacification), Cavitation concerning for Pneumonia, or Pneumonia, which does not meet criteria of a positive x-ray. As the radiologic criteria are not met, Pneumonia would not be assigned. If a physician or final impression of radiologic criteria had stated that the radiologic findings were suggestive/consistent with pneumonia, without utilizing the terms of persistent infiltrate, Consolidation or opacity, this would meet the radiologic criteria for pneumonia. In this scenario the physician based the diagnosis on the clinical findings and therefore the radiologic criteria are not met and Pneumonia would not be assigned..

36 Scenario 15: Postoperative SSI 12-year old patient Colectomy is the principal operative procedure. Abscess with pus was noted in operative report. Intraoperative cultures were positive for group C Streptococcus and acteroides. She was placed on antibiotics after the principal operative procedure due to the positive culture. On POD 6, the patient underwent a CT scan for abdominal pain. o CT impression: 1. Well-defined 3.5x4.0cm cystic area in the left adnexa. Differential includes postsurgical seroma, hematoma, phlegmon or possibly ovarian/parovarian cyst. o Patient underwent IR drainage of this cystic area. o Approximately 40 ml of straw-colored, non-purulent fluid was aspirated o Culture was negative. o The patient continued the course of the previously prescribed antibiotics which ended two days after the IR drainage.

37 Scenario 15: Postoperative SSI Which wound occurrence would be assigned to this case? A C D Superficial Incisional SSI Deep Incisional SSI Organ Space SSI None

38 Scenario 15: Postoperative SSI ANSWER D None Rationale: The patient was placed on antibiotics after the principal operative procedure due to the intraoperative findings. In this case, as the patient was already undergoing antibiotic therapy and there were no new antibiotics prescribed for the straw-colored, non-purulent fluid, drained in IR, an Organ/Space SSI would not be assigned to this case. When utilizing the Organ Space algorithm the intent is if the patient required a new addition or adjustment of antibiotics due to the findings of the possible abscess or drainage, this would indicate the findings are being treated as an infection.

39 Scenario 15: Postoperative SSI

40 Scenarios 16, 17: Documentation for Postoperative Occurrences Determine whether or not information given meets variable criteria to assign Documentation/follow up info must meet variable criteria to assign Assume information is within 30 day postoperative timeframe

41 Scenario 16: Documentation for Postoperative Occurrences Neurosurgeon noted clear drainage from recently revised VP shunt site, stated that fluid was likely CSF, and oversewed incision without testing drainage Would the occurrence of Superficial Wound Disruption be assigned to this case? A Yes No

42 Scenario 16: Documentation for Postoperative Occurrences ANSWER A Yes Rationale: Test to confirm drainage is CSF leak not needed for Superficial Wound Disruption.

43 Scenario 17: Documentation for Postoperative Occurrences Home health nurse reported to surgeon s office that the patient had purulent drainage from the surgical wound. Would a Superficial Incisional SSI be assigned to this case? A Yes No

44 Scenario 17: Documentation for Postoperative Occurrences ANSWER A Yes Rationale: Reported purulence alone is enough to assign Superficial SSIs.

45 Scenario 18: Wound Disruption Two month-old former 23 week preemie Principal operative procedure ventriculoperitoneal shunt placed POD 21, the infant s fontanelle is noted to be full and clear, colorless fluid identified as CSF is seen draining through the scalp skin incision. Which wound occurrence would be assigned to this case? A C D This is assigned as a Deep Wound Disruption because of the CSF leak. This is assigned as both a Superficial and a Deep wound disruption. This is assigned as a Superficial Wound Disruption. Deep Wound Disruption because of the shunt reservoir beneath the skin.

46 Scenario 18: Wound Disruption ANSWER C This is assigned as a Superficial Wound Disruption. Rationale: In this case, the CSF leak, through the skin incision indicates that there is at least a Superficial Wound Disruption. ecause there is a shunt reservoir beneath the skin, the CSF leak might be due to a leak from the reservoir connection or from a disruption of the deeper wound. Without exploration to determine the cause, a Deep Wound Disruption cannot be assigned.

47 Scenario 19: Postoperative SSI 16 year old patient Principal operative procedure: Roux-en-Y POD 8 o F oral o pain at the umbilical port site o The surgeon documents Purulent drainage noted from umbilical port site which is slightly tender and red. o The wound culture was negative. Which wound occurrence would be assigned to this case? A C D Superficial Incisional SSI Deep Incisional SSI Organ Space SSI None

48 Scenario 19: Postoperative SSI ANSWER A Superficial Incisional SSI Rationale: This patient example meets scenario 1 of the Superficial Incisional SSI definition of Purulent drainage, with or without laboratory confirmation, from the superficial incision. This example is assigned as a superficial SSI because the drainage from the superficial incision is described as purulent regardless if there is laboratory confirmation (positive wound culture) of infection or not.

49 Scenario 20: Postoperative Sepsis 8-week-old former 24-week gestation infant. Principal operative procedure exploratory laparotomy with an open ileostomy performed in the Neonatal Intensive Care Unit. Currently requiring jet ventilation with documented apnea and bradycardic episodes. WC count 30 INTRAOPERATIVE FINDINGS: cecal perforation with gross soilage of the peritoneal cavity with spilled stool. An ileocecectomy was performed, resecting the cecum with the perforation. A jejunostomy/proximal ileostomy was brought out. POD 1 o Patient placed on Dopamine o The surgeon noted: hemodynamic instability requiring dopamine with severe hypoxia with worsening CXR. o WC 37 o HR 185

50 Scenario 20: Postoperative Sepsis ased on the previous information, which level of postoperative Sepsis would be assigned to this case? A C D SIRS Sepsis Septic Shock None

51 Scenario 20: Postoperative Sepsis ANSWER C Septic shock Rationale: SIRS and infection criteria are met with the elevated WC and HR. SIRS met specified timeframe. The patient required dopamine; therefore, the postoperative occurrence of Septic Shock would be assigned. If Sepsis was present preoperatively without Septic Shock, progression to Septic Shock postoperatively is assigned as a Postoperative Occurrence of Septic Shock.

52 Scenario 21: Cardiac Risk 8-week-old former 24-week gestation infant. Principal operative procedure exploratory laparotomy with an open ileostomy in the Neonatal Intensive Care Unit Status post PDA closure with indomethacin. The patient s active problems include: Patent ductus arteriosus Persistent pulmonary hypertension Anemia of prematurity Which preoperative Cardiac diagnoses would be entered into the workstation?

53 Scenario 21: Cardiac Risk Which preoperative Cardiac diagnoses would be assigned to this case? A C D Pulmonary hypertension and Patent ductus arteriosus (PDA) repaired. Pulmonary hypertension and Patent ductus arteriosus (PDA) not repaired. Pulmonary hypertension and Patent ductus arteriosus (PDA) not repaired, and anemia of prematurity. Pulmonary hypertension, Patent ductus arteriosus (PDA) repaired, and anemia of prematurity.

54 Scenario 21: Cardiac Risk ANSWER A Pulmonary hypertension and Patent ductus arteriosus (PDA) repaired. Rationale: Pulmonary hypertension and Patent ductus arteriosus (PDA) repaired are on the Cardiac collect list; therefore, these diagnoses will be entered into the workstation. PDA repaired is assigned because the PDA is now closed.

55 Scenario 22: Cardiac Risk 8-week-old former 24-week gestation infant. Principal operative procedure exploratory laparotomy with an open ileostomy in the Neonatal Intensive Care Unit Status post PDA closure with indomethacin. Pulmonary hypertension and Patent ductus arteriosus (PDA) repaired have been entered in the workstation. What Cardiac Risk should be assigned to this case? A C D No cardiac risk factors Minor cardiac risk factors Major cardiac risk factors Severe cardiac risk factors

56 Scenario 22: Cardiac Risk ANSWER C Major cardiac risk factors Rationale: Major Cardiac Risk should be assigned to this case because the diagnosis of Pulmonary Hypertension is on the Major Cardiac Risk list. When the patient has multiple cardiac diagnoses, the highest level of risk is assigned.

57 Scenarios 23, 24, 25: Documentation for Postoperative Occurrences Determine whether or not information given meets variable criteria to assign Documentation/follow up info must meet variable criteria to assign Assume information is within 30 day postoperative timeframe

58 Scenario 23: Documentation for Postoperative Occurrences Neonatologist documents that patient has cardiovascular dysfunction and is in septic shock. Would the occurrence of Septic Shock be assigned to this case? A Yes No

59 Scenario 23: Documentation for Postoperative Occurrences ANSWER No Rationale: Septic Shock criteria must be met; further evaluation of documentation is needed.

60 Scenario 24: Documentation for Postoperative Occurrences Parent reports that patient was treated for UTI at the pediatrician s office. Would the occurrence of Urinary Tract Infection be assigned to this case? A Yes No

61 Scenario 24: Documentation for Postoperative Occurrences ANSWER No Rationale: must have + culture, symptoms to assign UTI; follow up w/ pediatrician to obtain culture and symptomology if possible.

62 Scenario 25: Documentation for Postoperative Occurrences A surgeon documents incisional wound intact with small amount of pus at incision on POD 21. Would this meet criteria to assign a Superficial Wound Disruption to this case? A Yes No

63 Scenario 25: Documentation for Postoperative Occurrences ANSWER No Rationale: There is no documentation that the incision is disrupted therefore no wound disruption would be assigned.